Human milk products useful in pre- and post-operative care

ABSTRACT

The present disclosure relates to human milk compositions and methods of making and using the same. In particular, the disclosure features methods of using human milk compositions to feed subjects before and/or after surgery or medical operations and that are useful in promoting recovery.

CROSS REFERENCE TO RELATED APPLICATIONS

This application claims priority to, and the benefit of U.S. ProvisionalApplication No. 62/273,243 filed Dec. 30, 2015, the contents of whichare incorporated herein by reference in their entireties.

FIELD OF THE INVENTION

The present disclosure relates to human milk compositions and methods ofmaking and using the same. In particular, the disclosure featuresmethods of using human milk compositions to feed subjects before and/orafter surgery or medical operations and that are useful in promotingrecovery and decreasing the length of time the subjects must spend inthe hospital. Thus, also provided herein are methods of promotingrecovery of a subject, particularly an infant, following surgery byfeeding those subjects one or more of the compositions described herein.

BACKGROUND OF THE INVENTION

Human milk is the ideal source of nutrition for premature infants,providing benefits in host defense, gastrointestinal maturation,infection rate, neurodevelopmental outcomes, and long-termcardiovascular and metabolic disease (Schanler, R. J., Outcomes of humanmilk-fed premature infants. Semin Perinatol, 2011. 35(1): p. 29-33). Anexclusive human milk (HM)-based diet significantly decreases the ratesof necrotizing enterocolitis (NEC), sepsis, days of parenteralnutrition, and death (Sullivan, S., et al., An exclusively humanmilk-based diet is associated with a lower rate of necrotizingenterocolitis than a diet of human milk and bovine milk-based products.J Pediatr, 2010. 156(4): p. 562-567.el; Cristofalo, E. A., et al.,Randomized trial of exclusive human milk versus preterm formula diets inextremely premature infants. The Journal of Pediatrics, 2013(163): p.1592-1595; Abrams, S. A., et al., Greater Mortality and Morbidity inExtremely Preterm Infants Fed a Diet Containing Cow Milk ProteinProducts. Breastfeeding Medicine, 2014. 9(6): p. 281-285).

Medical nutrition therapy is an important consideration for patientpopulations at risk of malnutrition. This is of particular importancefor infants undergoing surgery as these infants are at an increased riskfor growth failure, developmental delays, necrotizing enterocolitis,poor wound healing and late onset sepsis, with the risk increasing withearlier gestational age and lower birth weight as well as those infantswho require surgery soon after birth. Human milk is generally the foodof choice for all infants, regardless of gestational age at birthbecause of its nutritional composition and immunological benefits.

Breast milk may also be the optimal nutrition for pre- and post-surgicalinfants because of its ease of digestibility, nutritional composition,immunologic components and anti-infective benefits. (See, AAP COMMITTEEON NUTRITION, AAP SECTION ON BREASTFEEDING, AAP COMMITTEE ON FETUS ANDNEWBORN. “Donor Human Milk for the High-Risk Infant: Preparation,Safety, and Usage Options in the United States.” Pediatrics.2017;139(1):e20163440) Furthermore, infants undergoing surgery oftenfail to tolerate feeding regimens due to intolerance of artificialinfant formulas resulting in complete or partial supplementation withtotal parenteral nutrition (TPN) for extended periods of time increasingthe risk of metabolic derangements and TPN-associated complications.

Infants in need of surgery soon after birth include infants withcongenital birth defects affecting the major organs such as the heart,such as hypoplastic left heart syndrome and the intestine, such asgastroschisis and omphalocele as well as infants that develop conditionsrequiring surgery after birth, including infants that developnecrotizing enterocolitis (NEC).

Even when infants are able to tolerate breast milk feeding in and aroundthe time of surgery, unfortified human milk does not meet thenutritional needs of many of these infants necessitatingsupplementation, for example with TPN. The use of TPN and incompleteenteral breast milk feeding may result in intestinal brush borderdysfunction, dysbiosis (heavy growth of harmful bacteria in theintestine), metabolic disorders as well as TPN-related liver diseasehindering post-op recovery and impacting long term development. This isa particular concern when the infant's condition necessitates fluidrestriction, as is often the case with infants with congenital heartdisease. Recent data has shown that the energy content of human milkoften falls below generally accepted value of 20 kcal/oz (Wojcik, K. Y.,et al., Macronutrient analysis of a nationwide sample of donor breastmilk. Journal of the American Dietetic Association, 2009. 109(1): p.137-140; Vieira, A. A., et al., Analysis of the influence ofpasteurization, freezing/thawing, and offer processes on human milk'smacronutrient concentrations. Early Human Development, 2011. 87(8): p.577-580). As a result, the expected energy and nutrient content may notbe achievable in pen-operative infants, particularly those withcongenital heart disease where total fluid intake is restricted. Due tothe increased energy and macronutrient requirements of this populationwhen compared to the normal infants, the ability to provide the extracalories is an important step toward therapeutic intervention in thenutritional management of pre and post-surgical infants.

Thus, a nutritional solution is needed to prepare and assist infants inrecovery from surgery, particularly those who must maintain a fluidrestricted diet.

SUMMARY OF THE INVENTION

The current invention provides a high energy/high fat human milkcomposition that can be administered orally or enterally to increase thecaloric content of human donor milk or mother's own milk while notsubstantially increasing the overall volume or osmotic load necessary tomeet the nutritional requirements of these infants. The opportunity foran exclusive human milk diet in infants requiring surgery therebyimproves short and long term clinical outcomes including improved growthvelocity and wound healing resulting in a decreased length of hospitalstay (LOS) and improved neurodevelopment.

This disclosure features human milk compositions and methods of makingand using such compositions. In some embodiments the human milkcomposition is a human milk fortifier. In some embodiments, the humanmilk composition comprises milk and human milk fortifier. In someembodiments, the milk is human mother's milk. In other embodiments, themilk is pooled human milk. In some embodiments, the milk is aready-to-feed product. In other embodiments, the milk is non-human. Insome embodiments, the human milk composition comprises infant formula.

The present invention provides human milk compositions comprising fromabout 19 mg/mL to about 26 mg/mL protein, from about 49 mg/mL to about64 mg/mL fat, and from about 81 mg/mL to about 97 mg/mL carbohydrates.In another embodiment, the human milk composition comprises about 24 toabout 26 mg/mL protein, from about 60 mg/mL to about 64 mg/mL fat, andfrom about 83 mg/mL to about 97 mg/mL carbohydrates. In anotherembodiment, the human milk composition comprises about 19 to about 20mg/mL protein, from about 49 mg/mL to about 51 mg/mL fat, and from about81 mg/mL to about 89 mg/mL carbohydrates. In another embodiment, thehuman milk composition comprises about 21 to about 23 mg/mL protein,from about 54 to about 57 mg/mL fat, and about 82 to about 89 mg/mLcarbohydrates.

In one embodiment, the method provides administering to a subject ahuman milk composition comprising from about 19 mg/mL to about 26 mg/mLprotein, from about 49 mg/mL to about 64 mg/mL fat, and from about 81mg/mL to about 97 mg/mL carbohydrates. In another embodiment, the methodprovides administering to a subject a human milk composition comprisingabout 24 to about 26 mg/mL protein, from about 60 mg/mL to about 64mg/mL fat, and from about 83 mg/mL to about 97 mg/mL carbohydrates. Inanother embodiment, the method provides administering to a subject ahuman milk composition comprising about 19 to about 20 mg/mL protein,from about 49 mg/mL to about 51 mg/mL fat, and from about 81 mg/mL toabout 89 mg/mL carbohydrates. In another embodiment, the method providesadministering to a subject a human milk composition comprises about 21to about 23 mg/mL protein, from about 54 to about 57 mg/mL fat, andabout 82 to about 89 mg/mL carbohydrates.

In one embodiment, the human milk composition provides from about 67 toabout 139 kcal/kg/day. In another embodiment, the human milk compositionprovides from about 80 to about 130 mL/kg/day. In another embodiment,the human milk composition provides from about 90 to about 100mL/kg/day.

In one embodiment, the human milk composition further comprises one ormore constituents selected from the group consisting of: calcium,chloride, copper, iron, magnesium, manganese, phosphorus, potassium,selenium, sodium, and zinc. In another embodiment, the human milkcomposition further comprises human milk oligosaccharides.

In one embodiment, the human milk composition is administered to thesubject orally. In another embodiment, the human milk composition isadministered to the subject enterally.

In one embodiment, said subject is a human child, or infant. In aparticular embodiment, the child is from about 18 years old to about 2years old. In other embodiments, said subject is a child about two yearsold or younger. In another embodiment, said subject is less than orequal to 7 days old. In still other embodiments, said subject is apremature infant. In some embodiments, said subject is a human adult. Inone embodiment, the human adult is 18 years old or older.

In one aspect, the method comprises providing nutrition to a subject whois undergoing or has undergone surgery. In a further aspect, the methodcomprises administering to a subject a human milk composition comprisinga fortifier composition. In one embodiment, the human milk compositionprovides about 70% of the total nutrition and the fortifier compositionprovides about 30% of the total nutrition. In another embodiment, thehuman milk composition provides about 60% of the total nutrition and thefortifier composition provides about 40% of the total nutrition. Inanother embodiment, the human milk composition provides about 50% of thetotal nutrition and the fortifier composition provides about 50% of thetotal nutrition.

Human milk is defined as expressed breast milk or donor milk and itsderivatives, human milk-based fortifier and human milk caloricfortifier. Standard human milk formulation include Prolact-RTF™,PROLACTPLUS™ PROLACT+4®, PROLACT+6®, PROLACT+8®, and/or PROLACT+10®,which are produced from human milk and contain various concentrations ofnutritional components.

The disclosure features standardized human milk formulations orfortifiers, which are produced from human milk. Methods of making andusing such compositions are also described herein. In some embodiments,standardized human milk formulations are supplemented with vitaminsand/or minerals. In some embodiments, the standardized milk formulationsare fed orally to subjects who are undergoing or have undergone surgery.The methods of generating these compositions are designed to optimizethe amount of nutrients and calories in the compositions.

In some embodiments, the human milk compositions further comprise one ormore constituents selected from the group consisting of: calcium,chloride, copper, iron, magnesium, manganese, phosphorus, potassium,selenium, sodium, and zinc.

In one aspect, the disclosure features a human milk fortifiercomposition comprising: a human protein constituent from about 35 mg/mLto about 45 mg/mL and a human fat constituent from about 80 mg/mL toabout 100 mg/mL. In one aspect, the disclosure features a human milkfortifier composition comprising: a human protein constituent from about35 mg/mL to about 42 mg/mL and a human fat constituent from about 84mg/mL to about 95 mg/mL. In another aspect, the disclosure features ahuman milk fortifier composition comprising: a human protein constituentof about 37 to about 42 mg/mL and a human fat constituent of about 86 toabout 94 mg/mL. In another aspect, the disclosure features a human milkfortifier composition comprising: a human protein constituent of about39.2 mg/mL and a human fat constituent of about 94.5 mg/mL. Thecarbohydrate constituent can include additional lactose. In someembodiments, the composition further comprises one or more constituentsselected from the group consisting of: calcium, chloride, copper, iron,magnesium, manganese, phosphorus, potassium, selenium, sodium, and zinc.

In one aspect, a method for obtaining a human milk composition isprovided. In some embodiments, the method includes: (a) geneticallyscreening human milk for one or more viruses; (b) optionally filteringthe milk; (c) optionally heat-treating the milk, e.g., at about 63° C.or greater for about 30 minutes; (d) separating the milk into cream andskim; (e) adding a portion of the cream to the skim; and (f)pasteurizing or otherwise sterilizing the composition.

In some embodiments, the genetic screening in step (a) is polymerasechain reaction and/or includes screening for one or more viruses, e.g.,human immunodeficiency virus Type 1 (HIV-1), hepatitis B virus (HBV),and/or hepatitis C virus (HCV).

In some embodiments, the milk is optionally filtered through an about200-micron screen in step (b).

In some embodiments, the method further includes running cream, e.g.,about 30-70% fat in the cream, through a separator following step (d).In one embodiment, the method further includes filtering the skimthrough filters after step (d), e.g., to filter the water out of theskim. In some embodiments, after filtering the skim after step (d), thefilters used in the filtering is washed to obtain a post wash solution.In further embodiments, the post wash solution is added to the skim.

In some embodiments, the method further includes carrying out mineralanalysis of the portion of the composition obtained after step (e). Inone embodiment, the method also includes adding to the compositionobtained after step (e) one or more minerals selected from the groupconsisting of: calcium, chloride, copper, iron, magnesium, manganese,phosphorus, potassium, selenium, sodium, and zinc. Adding of the one ormore minerals includes heating the composition, in some embodiments.

In a particular embodiment, the method also includes cooling thecomposition after step (f), carrying out biological testing of a portionof the composition after step (f), and/or carrying out nutritionaltesting of a portion of the composition after step (f).

In some embodiments, the human milk of step (a) is pooled human milk.Thus, in some embodiments, the methods provided herein are carried outwith large volumes of the starting material, e.g., human milk, e.g.,pooled human milk. In some embodiments, the volumes can be in the rangeof about 75 liters/lot to about 10,000 liters/lot of starting material(e.g. about 2,500 liters/lot or about 2,700 liters/lot or about 3,000liters/lot or about 5,000 liters/lot or about 7,000 liters/lot, about7,500 liters/lot or about 10,000 liters/lot).

In another aspect, the disclosure features a method for obtaining ahuman milk composition. The method includes: (a) genetically screeninghuman milk for one or more viruses; (b) filtering the milk; (c) addingcream; and (d) pasteurizing.

In one embodiment, the genetic screening in step (a) is a polymerasechain reaction. In some embodiments, the genetic screening includesscreening for one or more viruses, e.g., HIV-1, HBV, and/or HCV.

In one embodiment, the milk is optionally filtered through an about 200micron screen in step (b). In some embodiments, the method furtherincludes ultra-filtering the whole milk after step (b) through filters.In some embodiments, the filters used during ultra-filtering are postwashed. In some embodiments, the filters used during ultra-filtrationare post washed with permeate. In some embodiments, the filters usedduring ultra-filtration are post washed with water.

In some embodiments, the composition is cooled after step (d). In someembodiments, biological and/or nutritional testing of the composition iscarried out after step (d).

In some embodiments, the human milk of step (a) is pooled human milk.Thus, in some embodiments, the methods featured herein are carried outwith large volumes of the starting material, e.g., human milk, e.g.,pooled human milk. In some embodiments, the volumes are in the range ofabout 75-10,000 liters/lot of starting material. In a particularembodiment, the volume is about 2,000 liters/lot. In another embodiment,the volume is about 2,500 liters/lot. In another embodiment, the volumeis about 2,700 liters/lot. In another embodiment, the volume is about3,000 liters/lot. In another embodiment, the volume is about 4,000liters/lot. In still another embodiment, the volume is about 5,000liters/lot. In still another embodiment, the volume is about 7,000liters/lot. In still another embodiment, the volume is about 7,500liters/lot. In still another embodiment, the volume is about 10,000liters/lot.

In some embodiments, the method includes adding to the compositionobtained after step (c) one or more minerals selected from the groupconsisting of: calcium, chloride, copper, iron, magnesium, manganese,phosphorus, potassium, selenium, sodium, and zinc.

In one aspect, a method is provided for improving one or more clinicaloutcomes subjects recovering from surgery. In some embodiments, the oneor more improved clinical outcomes comprise short and/or long termbenefits. In certain embodiments, the one or more improved clinicaloutcomes are selected from improved neurodevelopmental outcomes,improved growth velocity including rate of weight gain, incrementallinear growth, incremental rate of head circumference growth, reducedlength of stay in the hospital and a reduction of the days of parenteralnutrition. In some embodiments, the one or more improved clinicaloutcomes is selected from reduced incidence and/or severity of feedingintolerance, reduced incidence and/or severity of sepsis, reducedincidence and/or severity of necrotizing enterocolitis (NEC), redicedincidence and/or severity of wound infections, and/or wound dehiscence.Thus, in one aspect, methods for improving the clinical outcome ofsubjects, particularly infants, recovering from surgery is provided.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 is a flow chart showing the method of fortifier production.

FIG. 2 is a flowchart of an exemplary post-op feeding protocol.

FIG. 3 is a flowchart of the feeding intolerance algorithm.

FIG. 4 is a flowchart of the parenteral nutrition algorithm.

FIG. 5 is a chart of the weaning schedule.

DETAILED DESCRIPTION OF THE INVENTION

This disclosure features human milk compositions, e.g., a human milkfortifier, human milk fortifier mixed with mother's own milk andstandardized ready to feed human milk compositions, as well as methodsof making and using such compositions.

This disclosure also features standardized human milk formulations,which are produced from human milk. Methods of making and using suchcompositions are also described. These standardized human milkformulations can be used to feed subjects who are undergoing or haveundergone surgery, with or without mixing them with other fortifiers ormilk, for instance mother's own milk. Human milk formulations cancontain various caloric contents, for example, the human milkcompositions described herein can provide from about 67 to about 139kcal/kg/day, for example from about 90 to about 100 kcal/kg/day.

The compositions of the present disclosure are generated from humandonor milk, e.g., pooled milk, which undergoes rigorous geneticscreening, processing (e.g., to concentrate nutrients in the fortifiercompositions, and/or to reduce bioburden), and pasteurization. The milkcan be supplemented with various minerals and/or vitamins. Thus, thedisclosure also features methods of obtaining and processing milk fromhuman donors.

The methods of the present disclosure can be used to process largevolumes of donor milk, e.g., about 75-7,500 liters/lot of startingmaterial. In a particular embodiment, the volume is about 2,000liters/lot. In another embodiment, the volume is about 2,500 liters/lot.In another embodiment, the volume is about 2,700 liters/lot. In anotherembodiment, the volume is about 3,000 liters/lot. In another embodiment,the volume is about 4,000 liters/lot. In still another embodiment, thevolume is about 5,000 liters/lot. In still another embodiment, thevolume is about 7,000 liters/lot. In still another embodiment, thevolume is about 7,500 liters/lot. In still another embodiment, thevolume is about 10,000 liters/lot.

As used herein, the term “adulterant” refers to any non-human milk foundin human milk. The addition of adulterants to human milk is referred toas “adulteration”. Examples of adulterants include milk from non-humanspecies (e.g., cow milk, goat milk, etc.), milk-like products fromplants (e.g., soy milk) and infant formula.

As used herein, the term “contaminant” refers to the inclusion ofunwanted substances in human milk. While an adulterant is a“contaminant” generally the use of the term “contaminant” as used hereingenerally refers to other substances such as drugs, environmentalpollutants and/or bacteria and viruses. The inclusion of contaminants tohuman milk is referred to as “contamination.” The inclusion ofcontaminants may be due to any reason including but not limited toaccident, negligence or intent.

As used herein, the terms “surgery” and “surgical procedure” and“surgical operation” and “operation” or “operative care” or “operativeprocedure” are used interchangeably herein and refer to a medicalprocedure that uses operative manual and instrumental techniquesincluding any invasive (involving cutting) or non-invasive (i.e. wherethe internal organs are accessed via a bodily orifice) procedure done onthe human body to investigate and/or treat a pathological condition suchas disease or injury, to help improve bodily function or appearance orto repair unwanted ruptured areas.

As used herein, the terms “donor” and “individual” are usedinterchangeably and refer to a woman who supplies or provides a volumeof her milk, regardless of whether or not she is compensated, e.g.,monetarily, for the milk.

As used herein, the term “full-term” or “term infant” refers to infantborn in a range of 37 to 42 weeks gestation.

As used herein, the terms “preterm,” “preterm infant,” “premature,” or“premature infant” are used interchangeably and refer to infants bornbefore 37 weeks.

As used herein, the term “enteral feeding” refers to the delivery of anutritionally complete feed, containing protein, carbohydrate, fat,water, minerals and vitamins, directly into the stomach, duodenum orjejunum. Typically, in infants too premature to feed via a bottle orotherwise in infants unable to effectively feed from a bottle (eithermechanical or functional) short-term delivery of enteral feeds isaccomplished via placement of a nasogastric (NG) or nasojejunal (NJ)tube. If oral feedings are delayed for extended periods, more permanentfeeding tubes may be placed directly in the stomach as a gastrostomytube or in the small intestine as a jejunostomy tube.

As used herein, the terms “human milk”, “breast milk”, “donor milk”, and“mammary fluid” are used interchangeably and refer to milk from a human.

As used herein the term “child” or “children” refer to one (or more)human subjects who are under the age of 18.

As used herein the term “infant” refers to a child who is less than 1year old.

As used herein the term “adult” refers to a human who is 18 years old orolder.

As used herein, the term “parenteral nutrition” or refers to feeding asubject intravenously, bypassing the usual process of eating anddigestion. Compositions for parenteral nutrition contain nutrients suchas glucose, amino acids, vitamins and dietary minerals. Fats areadministered separately as a lipid emulsion by central or peripheralvein. Total parenteral nutrition (TPN) may refer to a situation where apatient receives the majority of nutrition via the parenteral route.However, the term TPN is often used in the art as well as herein,synonymously with the nutritional solution used for parenteralnutrition, regardless of the proportion of nutrition derived from thisroute. Parenteral nutrition may be administered through peripheral veinaccess in a limb or with a line placed in a large central vein.

As used herein, the term “whole milk” refers to human milk from which nofat has been removed.

As used herein, the term “bioburden” refers to microbiologicalcontaminants and pathogens (generally living) that can be present inmilk, e.g., viruses, bacteria, mold, fungus and the like.

As used herein, the term “congenital heart defect”, or CHD, refers to aproblem with the structure of the heart. Present at birth, congenitalheart defects are the most common type of birth defect. The defects caninvolve the walls of the heart, the valves of the heart, and thearteries and veins near the heart. The heart defects can disrupt thenormal flow of blood through the heart and its partitioning to theheart, body and brain. The blood flow can slow down, go in the wrongdirection or to the wrong place, or be blocked completely.

The terms “single ventricle physiology” or “single defect anomaly” or“single ventricle defect” refer to a variety of cardiac defects whereonly one of the heart's two ventricles are present or functionsproperly. As a result of having only one functioning ventricle, infantswith a single ventricle defect have a “Y” shaped circulation where theblood flows from the heart to both the lungs and the body. Further, theworking ventricle may be either the left or the right ventricle. Thus,in certain circumstances, it can be difficult to tell which pumpingchamber is working properly, making single ventricle physiology amongthe most complex defects of the heart.

The term “necrotizing enterocolitis” or “NEC” refers to a common andserious intestinal disease in preterm infants. It also occurs atincreased frequency in some term infants requiring surgery, for examplefor serious cardiac malformations. NEC occurs when tissue in the smallor large intestine is injured or begins to die off, possibly due tocauses such as too little oxygen or blood flow to the intestine atbirth, an underdeveloped intestine, injury to the intestinal lining,heavy growth of harmful bacteria in the intestine (dysbiosis) andformula feeding. The inability of the intestine to hold waste onceinjured could lead to escape of bacteria and other waste products intothe infant's bloodstream or abdominal cavity and possible subsequentinfection.

The term “sepsis” refers to a potentially life-threatening complicationof an infection. Sepsis happens when chemicals released into thebloodstream to fight the infection trigger inflammatory responsesthroughout the body. This inflammation can trigger a cascade of changesthat can damage multiple organ systems, causing them to fail.

By “mixed human milk composition” or “mixed composition” or “mixedformulation” or any human milk product indicated as “mixed” is meant acomposition wherein a fortifier has been mixed with a separate milkformulation for use in feeding to an infant. In some embodiments, thefortifiers described herein may be mixed with the infant's mother's ownmilk, donor milk, a standardized ready to feed human milk formulation orother human or non-human milk or infant formula. A “mixed composition”therefore is a ready to feed composition.

As used herein the term “ready to feed” when used to describe human milkformulations/compositions refers to milk that is ready to be fed to aninfant, that is in a form that is suitable for feeding to an infantwithout further dilution concentrating or mixing (i.e. not a fortifier).In some embodiments, the ready to feed composition is made by mixing afortifier with pasteurized donor breast milk, mother's own milk, orother standardized pasteurized breast milk formulation. In someembodiments, the ready to feed composition is formulated directly frompooled human milk donations and is provided to the infant in a form thatis ready to feed without additional mixing. Such ready-to-feedformulations derive directly from pooled human milk donations and arealso referred to as “standardized human milk formulations.” Theformulations are “standardized” because they contain specific (i.e.standardized) levels of constituents (i.e. fat, protein andcarbohydrates). Thus, as used herein “standardized high fat human milkformulations” or “high fat standardized human milk formulations” areready to feed formulations made directly producing the formulation frompooled human milk donations. While “ready to feed high fat formulations”are made either from mixing a high fat fortifier with ready to feed milk(mother's own milk, donor milk, or other standardized milk formulation)or are made directly from human milk donations.

As used herein “fortifier” means any human milk composition that isadded to another milk formulation (human or otherwise) to arrive at aready to feed formulation.

As used herein the term “pasteurization” refers to any method used toreduce bioburden or otherwise sterilize the human milk for humanconsumption. Methods of pasteurization include, but in no way arelimited to, the use of high temperatures for short periods of time (HTSTor “flash” pasteurization), the use of ultra-high temperatures forreally short periods of time (UHT). These methods may optionally becombined with homogenization of the milk and/or high pressure treatmentof the milk.

Nutritional Requirements of Subjects Preparing for and Recovering fromSurgery

Some infants require surgery soon after birth. After completion ofsurgery, patients are typically transferred directly from the operatingroom to the neonatal intensive care unit to be closely monitored. Whenthe patient is judged to have recovered from the anesthesia, he/she mayalso be transferred to a surgical ward or other intensive care unitelsewhere in the hospital. During the post-operative period, thepatient's general function and outcome of the procedure are assessed,and the surgical site is checked for bleeding, wound dehiscence or signsof infection. The likelihood of a positive post-operative recovery islinked to nutrition and immune health both prior to the surgery andafter. In fact, given the stress on the body and the energy needed torecover, infants that require surgery typically need more calories thanan infant without surgery procedures to maintain their basal metaboliclevels, to maintain and/or increase growth as well as to heal from thesurgery. Milk expressed by mothers of infants delivered after 37 weeksof gestation, however, generally does not meet this increased caloricdemand, as its biological function is in the nutrition of a healthy fullterm infant able to tolerate full volume feeds.

Subjects described herein include human adults, children, and/or infantsthat have or will undergo surgery. Infants include term and pre-terminfants. While the methods and protocols described here are done on 7day old infants or younger term infant, a person of skill in the artwould understand that the compositions and methods would be suitable forolder children, adults, and/or preterm infants. One of skill in the artwill readily be able to adapt the disclosure herein to meet thenutritional requirements of these older children and adults.

It is critical that the nutritional content of the daily feedings forinfants requiring or recovering from surgery meet acceptable levels ofkey components including total calories and protein contained within avolume they are able to tolerate. In this regard, the nutritionalsituation for infants requiring or recovering from surgery is similar tothat of preterm infants. However, the caloric content of the human milksupplied to infants is very rarely measured but is assumed to be 20calories/ounce. Traditional human milk fortifiers seek to increasecaloric content in part by increasing protein levels. However, whilethat strategy is appropriate to preterm infants, it may not beappropriate for term infants requiring surgery who are fluid restrictedand may not need as much protein for calories as a healthy term infant.

The human milk compositions described herein provide a solution to thisproblem and may be used to supplement human milk in order to increasethe caloric content to the desired level without providing an excess ofprotein and without increasing the volume to be fed to the infant, andin some instances decreasing the volume fed to the infant. This isparticularly useful when all that is needed is increased caloric intakeand not increased protein content. Similarly, provided herein arecompositions that are standardized high caloric human milk products thatcontain increased caloric content at similar or decreased volumescompared to donor milk, or mother's own milk, that may be used withoutfortification. The compositions of the current invention solve thisproblem by increasing calories without over supplying protein, andtherefore, provide a more cost effective solution to the problem whilealso avoiding possible liver and/or kidney dysfunction associated withexcess protein consumption.

The present disclosure features human milk compositions and methods ofmaking and using such compositions for feeding subjects who will undergoor have undergone surgery and who, because of their underlyingcondition, are fluid restricted. The particular human milk compositionsherein provide a unique balance of protein, fat and carbohydrates suchthat useful calories can be delivered without the need for large volumesof liquid. The human milk compositions can be used to reduce andeliminate the need for TPN.

Human Milk Compositions

The human milk fortifier compositions described herein are produced fromwhole human milk. The compositions featured herein contain variousamounts of nutrients, e.g., protein, carbohydrates, fat, vitamins, andminerals, as well as other milk components. Standardized human milkformulations (including donor milk or mom's own milk) can besupplemented with vitamins and/or minerals if desired and can be fedorally or enterally to subjects who are undergoing or have undergonesurgery. The methods of generating these compositions are designed tooptimize the amount of nutrients and calories in the compositions.

Human Milk Fortifier

The high energy/high fat human milk fortifier as featured herein can bemixed with human milk or other standardized human milk formulation toproduce a fortified human milk formulation suitable for administrationto an infant requiring or recovering from surgery. The human milkfortifier as described herein is made according to Table 1:

TABLE 1 Exemplary Human Milk Fortifiers Nutrient Range (mg/mL) Fat 86-94Protein 37-42 Carbs  75-110

In some aspect of the current invention, the fortifier described inTable 1 is mixed with human milk (either the infant's mother's own milk,donor milk or a standardized human milk composition, for example,Prolact-RTF™), cow's milk, or infant formula. Preferably, however thefortifier is mixed with fully human milk (e.g. mom's milk, donor milk orProlact-RTF™). In some embodiments, the human milk fortifier describedherein is mixed with human milk at a ratio of 50:50 to yield a mixturethat comprises the constituents as listed in Table 2, below. In someembodiments, the human milk fortifier described herein is mixed withhuman milk at a ratio of 70:30 to yield a mixture that comprises theconstituents as listed in Table 3, below. In some embodiments, the humanmilk fortifier described herein is mixed with human milk at a ratio of60:40 to yield a mixture that comprises the constituents as listed inTable 4, below. In some embodiments, the human milk fortifier is mixedwith cow's milk. In some embodiments, the human milk fortifier describedherein is mixed with cow milk at a ratio of 50:50 to yield a mixturethat comprises the constituents as listed in Table 2, below. In someembodiments, the human milk fortifier described herein is mixed with cowmilk at a ratio of 70:30 to yield a mixture that comprises theconstituents as listed in Table 3, below. In some embodiments, the humanmilk fortifier described herein is mixed with human milk at a ratio of60:40 to yield a mixture that comprises the constituents as listed inTable 4, below. In some embodiments, the human milk fortifier is mixedwith infant formula. In some embodiments, the human milk fortifierdescribed herein is mixed with infant formula at a ratio of 50:50 toyield a mixture that comprises the constituents as listed in Table 2,below. In some embodiments, the human milk fortifier described herein ismixed with infant formula at a ratio of 70:30 to yield a mixture thatcomprises the constituents as listed in Table 3, below. In someembodiments, the human milk fortifier described herein is mixed withhuman milk at a ratio of 60:40 to yield a mixture that comprises theconstituents as listed in Table 4, below.

Standardized Human Milk Formulations

The standardized human milk formulations featured herein are used toreduce and eliminate the need for TPN for subjects who are undergoing orhave undergone surgery. These standardized formulations include variousnutritional components for subject growth and development.

Exemplary standardized human milk compositions are found in Tables 2, 3,and 4. These standardized human milk compositions may be made directlyfrom donor milk and supplied in a ready to feed formulation or thesecompositions may be made by mixing appropriate quantities of the highfat human milk fortifiers described herein with donor milk, mother's ownmilk, and other ready to feed standardized feeding formulations of humanor non-human milk including cow's milk and infant formulas.

TABLE 2 Exemplary Human Milk Composition Nutrient Range (mg/mL) Fat60-64 Protein 24-26 Carbs 83-97

TABLE 3 Exemplary Human Milk Composition Nutrient Range (mg/mL) Fat49-51 Protein 19-20 Carbs 81-89

TABLE 4 Exemplary Human Milk Composition Nutrient Range (mg/mL) Fat54-57 Protein 21-23 Carbs 82-89

Specific Components of the Featured Compositions

One component of the milk compositions featured herein is protein. Inthe body, protein is needed for growth, synthesis of enzymes andhormones, and replacement of protein lost from the skin, urine andfeces. These metabolic processes determine the need for both the totalamount of protein in a feeding and the relative amounts of specificamino acids. The adequacy of the amount and type of protein in a feedingfor subjects is determined by measuring growth, nitrogen absorption andretention, plasma amino acids, certain blood analytes, and metabolicresponses.

Another constituent of the milk compositions described herein is fat.Fat is generally a source of energy for subjects, not only because ofits high caloric density but also because of its low osmotic activity insolution.

Vitamins and minerals are important to proper nutrition and developmentof subjects. A subject requires electrolytes, e.g., sodium, potassiumand chloride for growth and for acid-base balance. Sufficient intakes ofthese electrolytes are also needed for replacement of losses in theurine and stool and from the skin. Calcium, phosphorus and magnesium areneeded for proper bone mineralization and growth.

Trace minerals are associated with cell division, immune function andgrowth. Consequently, sufficient amounts of trace minerals are neededfor subject growth and development. Some trace minerals that areimportant include, e.g., copper, magnesium and iron (which is important,e.g., for the synthesis of hemoglobin, myoglobin and otheriron-containing enzymes). Zinc is needed, e.g., for growth, for theactivity of numerous enzymes, and for DNA, RNA and protein synthesis.Copper is necessary for, e.g., the activity of several importantenzymes. Manganese is needed, e.g., for the development of bone andcartilage and is important in the synthesis of polysaccharides andglycoproteins. Accordingly, the human milk formulations and compositionsof the invention can be supplemented with vitamins and minerals asdescribed herein.

Vitamin A is a fat-soluble vitamin essential for, e.g., growth, celldifferentiation, vision and proper functioning of the immune system.Vitamin D is important, e.g., for absorption of calcium and to a lesserextent, phosphorus, and for the development of bone. Vitamin E(tocopherol) prevents peroxidation of polyunsaturated fatty acids in thecell, thus preventing tissue damage. Folic acid plays a role in, e.g.,amino acid and nucleotide metabolism.

As described above, the variability of human milk vitamin and mineralconcentrations often require some fortification to insure that a childis receiving adequate amounts of vitamins and minerals. Examples ofvitamins and minerals that can be added to the human milk compositionsfeatured herein include: vitamin A, vitamin B1, vitamin B2, vitamin B6,vitamin B12, vitamin C, vitamin D, vitamin E, vitamin K, biotin, folicacid, pantothenic acid, niacin, m-inositol, calcium, phosphorus,magnesium, zinc, manganese, copper, selenium, sodium, potassium,chloride, iron and selenium. The compositions can also be supplementedwith: chromium, molybdenum, iodine, taurine, carnitine and choline mayalso require supplementation.

The osmolality of standardized human milk formulations featured hereincan affect adsorption, absorption, and digestion of the compositions.High osmolality, e.g., above about 400 mOsm/Kg H₂O, has been associatedwith increased rates of NEC, a gastrointestinal disease that affectsneonates (see, e.g., Srinivasan et al., Arch. Dis. Child Fetal NeonatalEd. 89:514-17, 2004). The osmolality of the human milk compositions ofthe disclosure is typically less than about 400 mOsm/Kg H₂O. Theosmolality can be adjusted by methods known in the art.

Methods of Making Human Milk Compositions

The human milk compositions described herein are produced from wholehuman milk. The human milk may be obtained from an infant's own motheror from one or more donors. In certain embodiments, the human milk ispooled to provide a pool of human milk. For example, a pool of humanmilk comprises milk from two or more (e.g., ten or more) donors. Asanother example, a pool of human milk comprises two or more donationsfrom one donor.

Obtaining Human Milk from Qualified and Selected Donors

Generally, human milk is provided by donors, and the donors arepre-screened and approved before any milk is processed. Varioustechniques are used to identify and qualify suitable donors. A potentialdonor must obtain a release from her physician and her child'spediatrician as part of the approval process. This helps to insure,inter alia, that the donor is not chronically ill and that her childwill not suffer as a result of the donation(s). Methods and systems forqualifying and monitoring milk collection and distribution aredescribed, e.g., in U.S. Pat. Nos. 8,545,920; 7,943,315; 9,149,052;7,914,822 and 8,278,046, which are incorporated herein by reference inits entirety. Donors may or may not be compensated for their donation.

Usually, donor screening includes a comprehensive lifestyle and medicalhistory questionnaire that includes an evaluation of prescription andnon-prescription medications, testing for drugs of abuse, and testingfor certain pathogens. The donor or her milk may be screened for, e.g.,human immunodeficiency virus Type 1 (HIV-1), HIV-2, human T-lymphotropicvirus Type 1 (HTLV-I), HTLV-II, hepatitis B virus (HBV), hepatitis Cvirus (HCV), and syphilis. These examples are not meant to be anexhaustive list of possible pathogens to be screened for.

Donors may be periodically requalified. A donor who does not requalifyor fails qualification is deferred until such time as they do, orpermanently deferred if warranted by the results of requalificationscreening. In the event of the latter situation, all remaining milkprovided by that donor is removed from inventory and destroyed or usedfor research purposes only.

A donor may donate at a designated facility (e.g., a milk bank office)or, in a preferred embodiment, express milk at home. If the donor willbe expressing milk at home, she will measure the temperature in herfreezer with, e.g., a supplied thermometer to confirm that it is coldenough to store human milk in order to be approved.

Testing Donor Identity

Once the donor has been approved, donor identity matching may beperformed on donated human milk because the milk may be expressed by adonor at her home and not collected at a milk banking facility. In aparticular embodiment, each donor's milk can be sampled for geneticmarkers, e.g., DNA markers, to guarantee that the milk is truly from theapproved donor. Such subject identification techniques are known in theart (see, e.g., U.S. Pat. No. 7,943,315, which is incorporated herein byreference in its entirety). The milk may be stored (e.g., at −20° C. orcolder) and quarantined until the test results are received.

For example, the methods featured herein may include a step forobtaining a biological reference sample from a potential human breastmilk donor. Such sample may be obtained by methods known in the art suchas, but not limited to, a cheek swab sample of cells, or a drawn bloodsample, milk, saliva, hair roots, or other convenient tissue. Samples ofreference donor nucleic acids (e.g., genomic DNA) can be isolated fromany convenient biological sample including, but not limited to, milk,saliva, buccal cells, hair roots, blood, and any other suitable cell ortissue sample with intact interphase nuclei or metaphase cells. Thesample is labeled with a unique reference number. The sample can beanalyzed at or around the time of obtaining the sample for one or moremarkers that can identify the potential donor. Results of the analysiscan be stored, e.g., on a computer-readable medium. Alternatively, or inaddition, the sample can be stored and analyzed for identifying markersat a later time.

It is contemplated that the biological reference sample may be DNA typedby methods known in the art such as STR analysis of STR loci, HLAanalysis of HLA loci or multiple gene analysis of individualgenes/alleles. The DNA-type profile of the reference sample is recordedand stored, e.g., on a computer-readable medium.

It is further contemplated that the biological reference sample may betested for self-antigens using antibodies known in the art or othermethods to determine a self-antigen profile. The antigen (or anotherpeptide) profile can be recorded and stored, e.g., on acomputer-readable medium.

A test sample of human milk is taken for identification of one or moreidentity markers. The sample of the donated human milk is analyzed forthe same marker or markers as the donor's reference sample. The markerprofiles of the reference biological sample and of the donated milk arecompared. The match between the markers (and lack of any additionalunmatched markers) would indicate that the donated milk comes from thesame individual as the one who donated the reference sample. Lack of amatch (or presence of additional unmatched markers) would indicate thatthe donated milk either comes from a non-tested donor or has beencontaminated with fluid from a non-tested donor.

The donated human milk sample and the donated reference biologicalsample can be tested for more than one marker. For example, each samplecan be tested for multiple DNA markers and/or peptide markers. Bothsamples, however, need to be tested for at least some of the samemarkers in order to compare the markers from each sample.

Thus, the reference sample and the donated human milk sample may betested for the presence of differing identity marker profiles. If thereare no identity marker profiles other than the identity marker profilefrom the expected subject, it generally indicates that there was nofluid (e.g., milk) from other humans or animals contaminating thedonated human milk. If there are signals other than the expected signalfor that subject, the results are indicative of contamination. Suchcontamination will result in the milk failing the testing.

The testing of the reference sample and of the donated human milk can becarried out at the donation facility and/or milk processing facility.The results of the reference sample tests can be stored and comparedagainst any future donations by the same donor.

Screening for Contaminants and Adulterants

The milk is also tested for pathogens. The milk is genetically screened,e.g., by polymerase chain reaction (PCR), to identify, e.g., viruses,such as HIV-1, HBV and HCV. A microorganism panel that screens forvarious bacterial species, fungus and mold via culture may also be usedto detect contaminants. For example, a microorganism panel may test foraerobic count, Bacillius cereus, Escherichia coli, Salmonella,Pseudomonas, coliforms, Staphylococcus aureus, yeast and mold. Inparticular, B. cereus is a pathogenic bacterium that cannot be removedthrough pasteurization. Pathogen screening may be performed both beforeand after pasteurization.

In addition to screening for pathogens, the donor milk may also betested for drugs of abuse (e.g., cocaine, opiates, synthetic opioids(e.g. oxycodone/oxymorphone) methamphetamines, benzodiazepine,amphetamines, and THC) and/or adulterants such as non-human proteins.For example, an ELISA may be used to test the milk for a non-humanprotein, such as bovine proteins, to ensure, e.g., that cow milk or cowmilk infant formula has not been added to the human milk, for example toincrease donation volume when donors are compensated for donations.

Adulterants include any non-human milk fluid or filler that is added toa human milk donation, thereby causing the donation to no longer beunadulterated, pure human milk. Particular adulterants to be screenedfor include non-human milk and infant formula. As used herein,“non-human milk” refers to animal-, plant- and synthetically-derivedmilks. Examples of non-human animal milk include, but are not limitedto, buffalo milk, camel milk, cow milk, donkey milk, goat milk, horsemilk, reindeer milk, sheep milk, and yak milk. Examples of non-humanplant-derived milk include, but are not limited to, almond milk, coconutmilk, hemp milk, oat milk, rice milk, and soy milk. Examples of infantformula include, cow milk formula, soy formula, hydrolysate formula(e.g., partially hydrolyzed formula or extensively hydrolyzed formula),and amino acid or elemental formula. Cow milk formula may also bereferred to as dairy-based formula. In particular embodiments, theadulterants that are screened for include cow milk, cow milk formula,goat milk, soy milk, and soy formula.

Methods known in the art may be adapted to detect non-human milkproteins, e.g., cow milk and soy proteins, in a human milk sample. Inparticular, immunoassays that utilize antibodies specific for a proteinfound in an adulterant that is not found in human milk can be used todetect the presence of the protein in a human milk sample. For example,an enzyme-linked immunosorbent assay (ELISA), such as a sandwich ELISA,may be used to detect the presence of an adulterant in a human milksample. An ELISA may be performed manually or be automated. Anothercommon protein detection assay is a western blot, or immunoblot. Flowcytometry is another immunoassay technique that may be used to detect anadulterant in a human milk sample. ELISA, western blot, and flowcytometry protocols are well known in the art and related kits arecommercially available. Another useful method to detect adulterants inhuman milk is infrared spectroscopy and in particular mid-range Fouriertransform infrared spectrometry (FTIR).

The human milk may be pooled prior to screening. In one embodiment, thehuman milk is pooled from more than one donation from the sameindividual. In another embodiment, the human milk is pooled from two ormore, three or more, four or more, five or more, six or more, seven ormore, eight or more, nine or more, or ten or more individuals. In aparticular embodiment, the human milk is pooled from ten or moreindividuals. The human milk may be pooled prior to obtaining a sample bymixing human milk from two or more individuals. Alternatively, humanmilk samples may be pooled after they have been obtained, therebykeeping the remainder of each donation separate.

The screening step will yield a positive result if the adulterant ispresent in the human milk sample at about 20% or more, about 15% ormore, about 10% or more, about 5% or more, about 4% or more, about 3% ormore, about 2% or more, about 1% or more, or about 0.5% or more of thetotal volume of the milk donation.

The screening of the donated human milk for one or more adulterants canbe carried out at the donation facility and/or milk processing facility.

Human milk that has been determined to be free of an adulterant, or wasfound to be negative for the adulterant, is selected and may be storedand/or further processed. Human milk that contains an adulterant will bediscarded and the donor may be disqualified. For example, if anadulterant is found in two or more human milk samples from the samedonor, the donor is disqualified. In another embodiment, if anadulterant is found in one or more human milk samples from the samedonor, the donor is disqualified.

Processing Human Milk

Once the human milk has been screened, it is processed to produce a highfat product, e.g., a human cream composition. The donation facility andmilk processing facility can be the same or different facility.Processing of milk can be carried out with large volumes of human milk,e.g., about 75 liters/lot to about 10,000 liters/lot of startingmaterial (e.g. about 2,500 liters/lot or about 2,700 liters/lot or about3,000 liters/lot or about 5,000 liters/lot or about 7,000 liters/lot,about 7,500 liters/lot or about 10,000 liters/lot).

Methods of obtaining compositions that include lipids from human milk toprovide nutrition to patients are described in U.S. Pat. No. 8,377,445filed on May 17, 2010 (National Stage Entry of PCT/US07/86973 filed onDec. 10, 2007), the contents of which are incorporated herein in theirentirety.

After the human milk is carefully analyzed for both identificationpurposes and to avoid contamination as described above, the milk canoptionally undergo filtering, e.g., through about a 200 micron filter,and the further optional step of heat treatment. For example, thecomposition can be treated at about 63° C. or greater for about 30minutes or more. Next, the milk is transferred to a separator, e.g., acentrifuge, to separate the cream (i.e., the fat portion) from the skim.The skim can be transferred into a second processing tank where itremains at about 2 to 8° C. until a filtration step. Optionally, thecream separated from the skim, can undergo separation again to removemore skim.

Following the separation of cream and skim, the skim portion undergoesfurther filtration, e.g., ultrafiltration. This process concentrates thenutrients in the skim milk by filtering out the water. The waterobtained during the concentration is referred to as the permeate. Theresulting skim portion can be further processed to produce human milkfortifiers and/or standardized human milk formulations.

Processing of human milk to obtain human milk fortifiers (e.g.,PROLACTPLUS™ Human Milk Fortifiers, e.g., PROLACT+4®, PROLACT+6®,PROLACT+8®, and/or PROLACT+10®, which are produced from human milk andcontain various concentrations of nutritional components) and thecompositions of the fortifiers are described in U.S. Pat. No. 8,545,920,filed on Nov. 29, 2007, the contents of which are incorporated herein intheir entirety. These fortifiers can be added to the milk of a nursingmother to enhance the nutritional content of the milk for, e.g., apreterm infant.

Methods of obtaining standardized human milk formulations (exemplifiedby PROLACT20™, and/or PROLACT24™) and formulations themselves are alsodiscussed in U.S. Pat. No. 8,545,920, filed on Nov. 29, 2007, thecontents of which are incorporated herein in their entirety. Thesestandardized human milk formulations can be used to feed, e.g., infants.They provide a nutritional human-derived formulation and can substitutefor mother's milk.

Use of Human Milk Compositions

The disclosed human milk compositions are particularly useful forproviding nutrition for subjects who are undergoing or have undergonesurgery in order to provide enough calories to meet the increasednutritional requirements associated with conditioning regimen beforesurgery, the complications resulting from the surgery procedure and thedemands of physical growth of subjects. The compositions of the presentinvention are useful in situations where infants and/or children requireenteral feeding. Feeding TPN is often used to feed subjects who haveundergone surgery. However, due to the negative effects associated withTPN, enteral feeding is desired. Enteral feeding can also be combinedwith TPN. The use of human lipids for parenteral nutrition, a practiceof intravenous feeding (e.g., total parenteral nutrition), for a patientin need thereof is described in U.S. Pat. Nos. 8,821,878 and 8,377,445the contents of each of which are incorporated herein in their entirety.

Compositions and methods of the present disclosure are useful inproviding nutrition to infants prior to surgery, after surgery, orbefore and after surgery.

Feeding guidelines prior to surgery may include providing human milkcompositions of the present invention at 2.5 ml/kg every three hours fora total of 20 ml/kg per day. If tolerating well, may advance feeds percue with a maximum volume as per standard practice at the center, forexample feeds may be advanced by 20 ml/kg per day every 24 hours for amaximum determined by the attending physician, for example the maximumfeed may be 60 ml/kg per day.

Feeding guidelines post-surgery may include a phased approach. Phase 1may comprise initiation of trophic feeds with human milk compositions ofthe present invention when ready as per attending physician at 1 ml perkg body weigh per day with a goal of 1 to 5 days. Phase 1 may alsoinclude the initiation of feeds at 20 ml/kg/day with continuedadvancements after 24 hours by 20 to 40 ml/kg/day. Phase 2 may compriseadvancing to a goal of about 60 to about 100ml/kg/day. Feedingadvancements may occur every 6-12 hours with progress to full feeds inPhase 2. Phase 3 may begin once phase 2 has been tolerated for 24 hours.Phase 3 may comprise advancing 10 to 20 ml/kg to a goal of about 130 toabout 140 ml/kg/day. Advancement to phase 4 may occur after tolerance inphase 3 has been observed for a minimum of 24 hours. Stepwisefortification may occur during each phase beginning at 24 cal/oz inphase 2, advancing to 26 calories/oz in Step 3 to 28 calories/oz in step4and finally 30 calories/oz at the completion of Step 4. If poor weightgain is demonstrated, additional advances of 10 to 20 ml/kg/day may beutilized and titrated to weight gain. One of skill in the art willunderstand that the above represents an exemplary protocol and that theexact timing of calorie and/or volume increases will depend on thepost-surgical situation that is encountered (e.g. gastroschisis vscardiac) or the subject being fed (e.g. a preterm infant vs a terminfant vs an older infant vs an adult).

All patents, patent applications, and references cited herein areincorporated in their entireties by reference. Unless defined otherwise,technical and scientific terms used herein have the same meaning as thatcommonly understood by one of skill in the art.

EXAMPLES

The following examples are intended to illustrate but not limit thedisclosure.

Example 1 Standardized Human Milk and Fortifier Products

In order to provide a nutritional supplement that can add the desiredamounts of calories to mother's own or donor milk without adding asignificant amount of volume, a human cream composition was producedthat can be delivered enterally, thereby avoiding the negative effectsassociated with TPN. Human milk from previously screened and approveddonors was mixed together to generate a pool of donor milk. In a cleanroom environment, the pool of donor milk was further tested for specificpathogens and bovine proteins. Specifically, PCR testing was used toscreen for the presence of HIV-1, HBV, and HCV in the milk. Amicrobiological panel was also performed that tests for, e.g., aerobiccount, Bacillius cereus, Escherichia coli, Salmonella, Pseudomonas,coliforms, Staphylococcus aureus, yeast and mold.

FIG. 1 is a chart showing an embodiment of generating a human milkfortifier. The screened, pooled milk undergoes filtering, e.g., throughabout a 200 micron filter (step 2), and heat treatment (step 3). Forexample, the composition can be treated at about 63° C. or greater forabout 30 minutes or more. Depending on the methods used, however, theinitial filtering and/or heat treatment step may be omitted. In step 4,the milk is transferred to a separator, e.g., a centrifuge, to separatethe cream from the skim. The skim can be transferred into a secondprocessing tank where it remains at about 2 to 8° C. until a filtrationstep (step 5).

Optionally, the cream separated from the skim in step 4, can undergoseparation again to yield more skim.

Following separation of cream and skim (step 4), a desired amount ofcream is added to the skim, and the composition undergoes furtherfiltration (step 5), e.g., ultrafiltration. This process concentratesthe nutrients in the skim milk by filtering out the water. The waterobtained during the concentration is referred to as the permeate.Filters used during the ultrafiltration can be postwashed and theresulting solution added to the skim to maximize the amount of nutrientsobtained. The skim is then blended with the cream (step 6) and samplestaken for analysis. At this point during the process, the compositiongenerally contains: about 8.5% to 9.5% of fat; about 3.5% to about 4.3%of protein; and about 8% to 10.5% of carbohydrates, e.g., lactose.

After the separation of cream and skim in step 4, the cream flows into aholding tank, e.g., a stainless steel container. The cream can beanalyzed for its caloric, protein and fat content. When the nutritionalcontent of cream is known, a portion of the cream can be added to theskim milk that has undergone filtration, e.g., ultrafiltration, (step 5)to achieve the caloric, protein and fat content required for thespecific product being made. Minerals can be added to the milk prior topasteurization.

At this point, the processed composition can be frozen prior to theaddition of minerals and thawed at a later point for further processing.Any extra cream that was not used can also be stored, e.g., frozen.Optionally, before the processed composition is frozen, samples aretaken for mineral analysis. Once the mineral content of the processedmilk is known, the composition can be thawed (if it were frozen) and adesired amount of minerals can be added to achieve target values.

After step 6 and/or the optional freezing and/or mineral addition, thecomposition undergoes pasteurization (step 7). For example, thecomposition can be placed in a process tank that is connected to thehigh-temperature, short-time (HTST) pasteurizer via platinum-curedsilastic tubing. After pasteurization, the milk can be collected into asecond process tank and cooled. Other methods of pasteurization known inthe art can be used. For example, in vat pasteurization the milk in thetank is heated to a minimum of 63° C. and held at that temperature for aminimum of thirty minutes. The air above the milk is steam heated to atleast three degrees Celsius above the milk temperature. In oneembodiment, the product temperature is about 66° C. or greater, the airtemperature above the product is about 69° C. or greater, and theproduct is pasteurized for about 30 minutes or longer. In anotherembodiment, both HTST and vat pasteurization are performed.

The resulting fortifier composition is generally processed aseptically.After cooling to about 2 to 8° C., the product is filled into containersof desired volumes, and various samples of the fortifier are taken fornutritional and bioburden analysis. The nutritional analysis ensuresproper content of the composition. A label that reflects the nutritionalanalysis is generated for each container. The bioburden analysis testsfor presence of contaminants, e.g., total aerobic count, B. cereus, E.coli, Coliform, Pseudomonas, Salmonella, Staphylococcus, yeast, and/ormold. Bioburden testing can be genetic testing.

The product is packaged and shipped once the analysis is complete anddesired results are obtained.

Example 2 Use Of Human Milk Products For Infants Undergoing Surgery

A randomized controlled trial is undertaken to evaluate growth velocityand clinical outcomes of infants with single ventricle physiology fed anexclusive human milk diet with early nutritional fortification followingsurgical repair. While the methods and clinical protocol describedherein are done on a 7 day old or younger term infant, a person of skillin the art would understand that the compositions and methods would besuitable for older children, adults and pre-term infants.

In the United States, about 40,000 births per year are associated with acongenitally malformed heart. Infants with single ventricle physiology(−15% of all CHD) face a significant challenge in terms of growth bothshort and long term, particularly after the first palliative surgeryduring the inter-stage (Anderson J B, Iyer S B, Schidlow D N et al.Variation in Growth of infants with single ventricle. J Pediatrics2012;161:16-21).

Currently, the standard of care is to feed these infants withunfortified human milk or formula until infant is almost at full feeds.Early feeding of fortified human milk has been shown to improve growthin a neonatal population at highest risk for growth failure such aspreterm infants, (Cristofalo E A, Schanler R J, Blanco C L, et al.Randomized trial of exclusive human milk versus preterm diets inextremely premature infants. J Pediatrics, doi:10.1016/j.jpeds.2013.07.011, 2013. Hair A B, Hawthorne K M, Chetta K E,Abrams S A. Human milk feeding supports adequate growth in infants ≤1250grams birth weight. BMC Res Notes, 2013, 6:459. Doi:10.1186/1756-0500-6-459.) In addition, it has been well-demonstratedover the past few years that extremely premature infants (<1250 gbirthweight) fed a 100% human milk diet demonstrate significantly betterclinical outcomes, e.g. decreased incidence of NEC and time spent onintravenous feedings (TPN), than babies fed a diet containing any cowmilk-based components. Currently, all participating centers do notutilize an exclusive human milk diet in term infants with a singleventricle physiology heart defect as they need increased caloric intakevia fortification utilizing cow's milk derived products(fortifiers/formula). While their growth patterns are similar when astandard nutritional protocol is used, a much more aggressive protocolis possible with a 100% human milk diet resulting in improved growth atsimilar nutritional volumes (Hair, 2013).

In this single blinded (physician investigator), randomized, controlledtrial we evaluate growth velocity and clinical outcomes in infants withsingle ventricle physiology fed an exclusive human milk diet duringtheir initial hospitalization after birth and through the 30 dayspost-surgical repair feeding period or hospital discharge, whichevercomes first.

The study population comprises infants less than or equal to 7 days oldwith single ventricle cardiac physiology whose enteral nutrition, ifany, consists of an exclusive human milk diet prior study enrollment andwho require surgical palliation within the first 1 month of life.

Subjects are randomized to one of two groups (described in more detailbelow) at birth or immediately following diagnosis if prenatal care wasnot obtained prior to birth. Parents who decline participation by theirinfants in the study are asked to consent to data gathering on theirinfants who will be treated and fed per institutional practice. The dataon these individuals is summarized and evaluated descriptively incomparison with the actual trial results. Any infant who is randomizedand has undergone cardiac repair will continue on the intervention evenif exclusion criteria are later discovered (i.e. microarray comes backpositive for 22q11 deletion). Infants are terminated from study if isnot in the best interest of the infant (i.e. chylothorax, NEC)

All patients receive exclusive maternal human milk or donor human milkprior to randomization. Once randomized, patients in Group One receivean exclusive human milk diet prior to the surgery and throughout the 30day feeding period following surgical repair or until hospitaldischarge, whichever comes first. Day 1 is defined as the day of thefirst enteral feed post-surgery. Patients in Group Two (Control Group)receive maternal human milk or formula or donor human milk (per standardof care at each hospital) in the pre-surgical period. During thepost-surgical period, the control group receives human milk or formula,as per feeding algorithm.

The primary objective is to evaluate growth velocity (weight velocity[g/kg/day] and weight z-score from WHO growth charts) at 30 days afterthe initiation of feed post-surgery for infants with single ventriclephysiology who are fed an exclusive human milk diet from birththroughout the 30 day feeding period following surgical repair or untilhospital discharge, whichever comes first. Day 1 is defined as the dayof the first enteral feed post-surgery.

The secondary objectives are to evaluate the role of an exclusive humanmilk diet with regards to secondary measures of growth such as the rateof linear growth (cm/week and z-score from WHO growth charts) andincremental rate of head circumference growth (cm/week and z-score fromWHO growth charts) over the duration of the initial 6 months of thepost-surgical period or prior to the 2^(nd) stage palliation surgerywhichever came first. Additional secondary measures include 1) Feedingintolerance defined as nil per os (NPO) for at least 24 hours in the 30days of post-surgery enteral feeding period (day 1 is the first day offeeding post-op). NPO due to elective surgeries or procedures will notbe defined as feeding intolerance 2) Post-operative length of stay inthe hospital and length of stay in the intensive care/cardiac unit 3)Incidence of key morbidities in the 30 day post-surgical period, suchas:

-   -   Confirmed sepsis (defined as clinical signs and symptoms        consistent with sepsis in association with the isolation of a        causative organism from a culture of blood. A definitive        demonstration of infection must include one or more of the        following: 1) positive blood cultures (in cases of        Coagulase-negative Staphylococcus [CoNS] at least two positive        cultures separated temporally and physically are required.) 2)        positive urine cultures 3) positive CSF cultures. For the        purposes of this endpoint only culture-proven sepsis will be        evaluated in the analyses. The number of cultures taken for each        patient will be recorded to collect data in regards of number of        events of “suspected sepsis” vs “confirmed sepsis”.    -   Necrotizing enterocolitis (NEC), defined as stage II or greater        per Bell's criteria and whether surgical intervention was        required    -   Wound infections defined as per CDC Surgical Site infection:        Infection that occurs within 30 days after any operative        procedure and involves only skin and subcutaneous tissue of the        incision and has at least one of the following: a) purulent        drainage; b) organisms identified from an aseptically-obtained        specimen from the superficial incision or subcutaneous tissue by        a culture or non-culture based microbiologic testing methods        which is performed for purposes of clinical diagnosis or        treatment (not surveillance); c) superficial incision that is        deliberately opened by a surgeon/attending physician and patient        has at least one of the following signs or symptoms: pain or        tenderness, localized swelling, erythema, or heat; d) diagnosis        of a superficial incisional SSI by the surgeon or attending        physician. Cellulitis, stitch abscess alone or localized pin        site infection does not qualify. Classify as deep if it involves        deep soft tissues (fascia and muscle layers).    -   Wound dehiscence that requires intervention (wound vac)    -   Days of parenteral nutrition (PN) in the 30 day post-surgical        period

Developmental outcome are evaluated based on Bayley III score at 18-24months.

Data regarding cardiac anatomy and physiology risk factors, as assessedby routine echocardiography, are periodically collected throughout thestudy period from preoperative period to 18 to 24 months evaluation(ideally at pre-first surgery, at pre-2^(nd) stage palliation surgery,within 1 week post-surgery if obtained as standard of care, and at 18-24months). This included data regarding: congenital heart anatomicsubtype, qualitative assessment of dominant ventricular function,qualitative assessment of AV valve regurgitation, degree of systemicoutflow obstruction (aortic stenosis or coarctation) degree of aorticinsufficiency, and presence of residual pulmonary venous obstruction.

Quality objectives included length of time on human milk dietpost-discharge at the 3, 6 and 18-24 month follow up visits.

Supportive variables included time from birth to surgical repair, needfor cardiac re-operation, need for interventional cardiaccatheterization, data collection of any non-cardiac surgery andextracorporeal membrane oxygenation (ECMO), and major STSmorbidities/complications (Jacobs M L, O'Brien S M, et al. Anempirically based tool for analyzing morbidity associated withoperations for congenital heart disease. J Thorac. Cardiovasc. Surg.2013; 145: 1046-1057) Major STS morbidities/complications as defined bylocal STS database managers include complete heart block (CHB) requiringpacemaker (PM), diaphragm paralysis requiring plication, tracheostomy atdischarge, renal failure requiring dialysis, new post-operativeneurological deficit persisting at discharge, need for post-opmechanical circulatory support, unplanned re-operation.

In addition, once a week a sample of the human milk (4 ml of breast ordonor thawed to prepare the feeding for the day before any fortificationis added) being fed are tested for macronutrient content (calories,protein, carbohydrates and fat). The frequency of direct breastfeedingper day are recorded during the study intervention. The length of timethe patient is fed breastmilk is recorded at the follow up visits.

As a result of earlier fortification and better feeding tolerance, theinfants have improved growth and wound healing; in addition to theimmunological and anti-inflammatory benefits of an exclusive human milkdiet, complications that occur post-surgical repair are reduced. Theoverall length of stay in the hospital and the associated cost ofextended hospitalization are decreased. Furthermore, there is lowerincidence of confirmed sepsis and other morbidities such as NEC.

Feeding Management PRE-surgery

1. Readiness to feed is determined by the clinician team. Criteria toconsider to initiate enteral feeds in an attempt to standardize betweencenters include 1) Hemodynamically stable (stable vital signs perattending physician), reasonable urine output (>2ml/kg/hour) and goodperfusion by exam 2) Minimal or no acidosis, based on stable lactatelevels or base deficit 3) Receiving no or low vasoactive support for atleast 12 hours, May be on milrinone and either dopamine ≤3 mcg/kg/min orepinephrine ≤0.03 mcg/kg/min. OK if receiving prostaglandin (PGE 1), andOK if UAC or UVC in place. The Wernovsky inotrope score will becalculated for information purposes (Wernovsky et al., 1995). Notfollowing these criteria is NOT considered a violation of protocol.

2. Initiate PO feeds (20 ml/kg/day) if tolerating well may advance POfeeds per cues with a maximum volume as per standard practice at thecenter.

3. If not engaged in PO feeds but meets above criteria: May keep NPO ORSTART TROPHIC FEEDS at (20 ml/kg/day) via OG, NG or NJ .

4.TYPE OF FEEDING AFTER RANDOMIZATION: If infant is in Group 1 (Studygroup), infant will receive maternal human milk or donor human milk. Ifinfant is in Group 2 infant will receive human milk (maternal or donor)or formula (Any term formula 20 cal/oz) as per standard of care at eachhospital. Research coordinator, dietitian and dietary techs will beunblinded to group allocation. All treating clinicians to include:attending physicians, residents, fellows, RN's, APN's will remainblinded to group allocation.

Criteria for NOT feeding pre-surgery include 1) Feeding difficulties orother intestinal disease such as dysmotility as determined by treatingphysicians which may include increase in abdominal girth, emesis,paucity of bowel sounds, no stool for >48 hours with a history ofregular stooling, increased gastric residuals if NG feeding as perstandard practice at the hospital (Infants with NEC or intestinalsurgical intervention are excluded from study) and 2) Infant withhistory of pre-operative shock and/or multi-organ failure (diagnosedwith at least 2 of the following active diagnoses: Acute tubularnecrosis, acute liver failure with coagulopathy, intestinal bleeding).Clinician to determine if pre-operative shock and multi-organ failure issevere enough to not feed.

Feeding Management Post-surgery

1. Readiness to feed is determined by the clinician team. Criteria toconsider to initiate enteral feeds in an attempt to standardize betweencenters include 1) Hemodynamically stable (stable vital signs perattending physician), reasonable urine output (>2 ml/kg/hour) and goodperfusion by exam, 2) Minimal or no acidosis, based on stable lactatelevels or base deficit and 3) Receiving no or low vasoactive support forat least 12 hours, May be on milrinone and either dopamine ≤3 mcg/kg/minor epinephrine ≤0.03 mcg/kg/min. OK if receiving prostaglandin (PGE 1),and OK if UAC or UVC in place. The Wernovsky inotrope score will becalculated for information purposes (Wernovsky et al., 1995). Notfollowing these criteria is NOT considered a violation of protocol.

2. Follow Post-surgical feeding algorithm (FIG. 2) for feeding volume,type, fortification and advancement. In brief, fortification will beinitiated at 60 ml/kg/day in the exclusive human milk group; the controlgroup will initiate fortification as per ordinary care at theparticipating institution in the post-surgical period (expected to be at100 ml/kg/day).

3. Suggest following feeding intolerance algorithm for holding/advancingfeeds (FIG. 3). Feeds can be held at the discretion of physician, notfollowing algorithm is NOT considered a deviation of protocol.

Criteria for NOT feeding post-surgery include 1) Feeding difficulties orother intestinal disease such as dysmotility as determined by treatingphysicians including increase in abdominal girth, emesis, paucity ofbowel sounds, no stool for >48 hours with a history of regular stooling,increased gastric residuals if NG feeding as per standard practice atthe hospital (Infants with NEC or intestinal surgical intervention areexcluded from study), 2) Infant with history of pre-operative shockand/or multi-organ failure (diagnosed with at least 2 of the followingactive diagnoses: Acute tubular necrosis, acute liver failure withcoagulopathy, intestinal bleeding). Clinician to determine ifpre-operative shock and multi-organ failure is severe enough to not feedand 3) Presence of chylothorax. If developed while on study, infant willbe off protocol.

Type of feeding and fortification at a certain volume is protocoldriven. The specific post-op nutritional protocol is given in one year,more than one year, more than two years, more than three years, morethan four years, more than five years, and any duration longer than fiveyears. In particular embodiments of any of the methods described herein,a treatment regimen comprises a subject being provided with the halogencompound, e.g., iodide, over a period of a lifetime. Cliniciansdetermine enteral volume, frequency to be given to infant per day androute (PO/NG/NJ). The order should read: type of feeding andfortification as per protocol. Otherwise this study will not alter themedical and/or surgical management of patients with single ventriclephysiology.

In both the investigational and control groups, TPN is given in both thepre-surgical and immediate post-surgical period as needed according tothe attending physicians (see FIG. 4 for suggested TPN algorithm). Theamount of TPN given each day will be recorded in terms of volume, kcaland protein. This overall randomization process will be performed withineach of the study centers.

Randomization between the study groups will be performed using apermuted block randomization scheme (with the block size remainingblinded to study investigators). A predetermined randomization tablewill be provided to each study site by the study statistician and thiswill be given to an individual at each site not responsible for patientevaluation. Randomization will take place as soon as the infant isenrolled in the study. Study allocation will be disclosed to researchcoordinator, dietitians, and dietary techs in order to follow feedingalgorithm and ensure appropriate fortification and type of milk isprovided to each patient. All treating clinicians to include: attendingphysicians, residents, fellows, RN's, APN's will remain blinded to groupallocation but the stage of fortification will be disclosed upon request(stage as defined in post-op feeding algorithm, FIG. 2).

Infants remain on this feeding algorithm for 30 days or until discharge,whichever comes first. Once discharge is being anticipated,transitioning off donor human milk and fortifier will begin and willfollow the weaning table (FIG. 5). Once an infant is completely offHuman Based Milk Fortifier (Prolacta Product), formula/HMF will be addedto provide a minimum of 24 kcal/oz per the individual site's practicefortification can be adjusted as per attending physician. For thecontrol group (study arm 1) transition to a discharge formula will notoccur as they are already receiving formula/HMF. Once an infant is offintervention, fortification can be adjusted as per the attendingphysician.

Transition to discharge feeding regimen is summarized in FIG. 5 and isonly needed for infants strictly on human milk arm. If anticipatingdischarge within 5 days begin transition off DBM (donor breast milk)following feeding chart below. Optionally, transition day 3 may beskipped. If EBM (expressed breast milk) is available transition to EBMfortified to 24 kcal/oz with term formula. If standard of care is todischarge on donor human milk at that facility then it can be used. Ifno EBM is available transition to TERM formula fortified to 24 kcal/oz.TERM Formula to be used can be chosen per facility by Dietitian orCardiac team, Minimum concentration of 20 cal/oz during interventionperiod. Direct breast feeding may be incorporated into feeding regimenper facility.

Example 3 Statistical Analysis

Quantitative data are summarized using mean±standard deviation and/ormedian±interquartile range, and qualitative data will be summarizedusing proportions and percentages.

The primary endpoints of the study include weight velocity (g/kg/day) inthe 30 day enteral feeding period following surgical repair or untilhospital discharge, whichever comes first, as well as length (cm/week)and head circumference growth (cm/week)in the first 6 monthspost-surgery (or prior to the 2^(nd) palliation surgery).

The experimental and control groups will be compared using the Wilcoxonrank-sum test in each case. The calculation of weight velocity ing/kg/day will be based on the method proposed by Patel et al. (2009).Calculation of length and head circumference velocity will be based onthe change in the measurements from the initial reading to the lastvalue obtained in the relevant time period divided by the time frame inweeks.

The incidences of any feeding intolerance, confirmed sepsis, NEC, woundinfection and wound dehiscence will be compared between the study groupsusing the Fisher's exact test. While these analyses look only at whetheror not these outcomes occurred, if there are multiple occurrences, therates will be evaluated using the two-sample exact test of Poisson rates(based on the algorithm found in the program StatXact 11).

The length of stay in the hospital, length of stay in the intensivecare/cardiac unit and days of parenteral nutrition in the post-surgicalperiod will be compared using the Wilcoxon rank-sum test. However, ifthere is any censoring (e.g. if the infant is transferred or dies) ineither of these variables, the data will be evaluated using theKaplan-Meier estimation scheme and compared with the log rank test.

Multivariate regression models (linear for quantitative variables, Coxproportional hazards for censored data, logistic for qualitative data,and Poisson for count data) may be used in a secondary adjusted analysisto account for pre-defined relevant covariates (i.e. birth weight,gender, type of surgical procedure, etc.). In all analyses, significancewill be declared for any p-value less than 0.05 with no adjustment formultiple endpoints.

For developmental outcomes, the Bayley scores at 18-24 months will becompared using the Wilcoxon rank sum test.

For exploratory objectives, various quantitative measures obtained fromthe echo cardiography are evaluated using the Wilcoxon rank-sum test andcategorical outcomes will be compared between the groups using eitherthe Fisher's exact test (dichotomous data) or the chi-square test forhomogeneity using an exact calculation of the p-value (StatXact 11) formultichotomous outcomes.

For quality objectives, length of time on an exclusive human milk dietpost-discharge at the 3 and 6 month (+/−2 weeks) and the 18-24 monthfollow up visits are individually evaluated by the Wilcoxon rank-sumtest. However, if the information is not completely known at a specifictime, then the log rank test will be used because of censoring.

For supportive variables, the time from birth to surgical repair will beanalyzed using the Wilcoxon rank-sum test. The need for re-operationwill be compared between the groups using Fisher's exact test.

What is claimed is:
 1. A human milk fortifier composition comprisingabout 35 to about 45 mg/ml protein and from about 80 to about 100 mg/mlfat.
 2. The composition of claim 1, wherein the human milk fortifiercomposition comprises about 37 to about 42 mg/ml protein and from about86 to about 94 mg/ml fat.
 3. The composition of claim 1, wherein thehuman milk fortifier composition comprises about 35 to about 42 mg/mlprotein and from about 84 to about 95 mg/ml fat.
 4. The composition ofany of claims 1-3, wherein the human milk fortifier composition canfurther comprise one or more constituents selected from the groupconsisting of: calcium, chloride, copper, iron, magnesium, manganese,phosphorus, potassium, selenium, sodium, and zinc.
 5. A human milkcomposition comprising about 50% pooled donor milk and 50% human milkfortifier.
 6. The composition of claim 5 wherein the compositioncomprises about 20 to about 30 mg/ml protein, about 60 to about 70 mg/mlfat, and about 80 to about 100 mg/ml carbohydrates.
 7. The compositionof claim 5 wherein the composition comprises about 24 to about 26 mg/mlprotein, about 60 to about 64 mg/ml fat, and about 83 to about 97 mg/mlcarbohydrates.
 8. A human milk composition comprising 70% pooled donormilk and 30% human milk fortifier.
 9. The composition of claim 8 whereinthe composition comprises about 10 to about 20 mg/ml protein, about 40to about 50 mg/ml fat, and about 80 to about 90 mg/ml carbohydrates. 10.The composition of claim 8 wherein the composition comprises about 19 toabout 20 mg/ml protein, about 49 to about 51 mg/ml fat, and about 81 toabout 89 mg/ml carbohydrates.
 11. A method for providing nutrition to asubject who is about to undergo or has undergone surgery, the methodcomprising administering to said subject a human milk compositionaccording to any of claims 1-10.
 12. A method for providing nutrition toa subject who is about to undergo or has undergone surgery, the methodcomprising administering to said subject a human milk compositionaccording to any of claims 8-10.
 13. A method for providing nutrition toa subject who has undergone surgery, the method comprising administeringto said subject a human milk composition according to any of claims 1-7.14. The method of claim 10, wherein the human milk composition isadministered at about 67 to about 139 kcal/kg/day.
 15. The method ofclaim 11, wherein the human milk composition is administered at about 90to about 100 mL/kg/day.
 16. The method of claim 11, wherein the humanmilk composition is administered orally or enterally.
 17. The method ofclaim 11, wherein the subject is about two years old or younger.
 18. Ahuman milk composition comprising: a human protein constituent fromabout 20 to about 30 mg/ml protein, a human fat constituent from about60 to about 70 mg/ml fat, and human carbohydrate constituent from about80 to about 100 mg/ml carbohydrate.
 19. The human milk composition ofclaim 18, wherein the human protein constituent is about 25 mg/ml; thehuman fat constituent is from about 64 mg/ml; and the human carbohydrateconstituent is about 85 mg/ml.
 20. A human milk composition comprising:a human protein constituent from about 10 to about 20 mg/ml protein, ahuman fat constituent from about 40 to about 50 mg/ml fat, and humancarbohydrate constituent from about 80 to about 90 mg/ml carbohydrate.21. The human milk composition of claim 20, wherein the human proteinconstituent is about 19 mg/ml; the human fat constituent is from about51 mg/ml and the human carbohydrate constituent is about 82 mg/ml. 22.The human milk composition of claim 20, wherein the carbohydrateconstituent further includes lactose.
 23. The human milk composition ofclaim 22, wherein the composition further comprises one or moreconstituents selected from the group consisting of: calcium, chloride,copper, iron, magnesium, manganese, phosphorus, potassium, selenium,sodium, and zinc.
 24. A method for improving one or more clinicaloutcomes in a subject who has undergone surgery comprising administeringto said subject a human milk composition according to any of claims1-10.
 25. The method of claim 24 wherein the one or more improvedclinical outcomes comprises improved neurodevelopmental outcomes,improved growth velocity including rate of weight gain, incrementallinear growth, incremental rate of head circumference growth, reducedlength of stay in the hospital and/or a reduction of the days ofparenteral nutrition.
 26. The method of claim 24 or 25 wherein the oneor more improved clinical outcomes comprises a reduced incidence offeeding intolerance, sepsis, necrotizing enterocolitis (NEC), woundinfection and/or wound dehiscence.
 27. The method of any one of claims24-26, wherein the human milk composition is administered at about 67 toabout 139 kcal/kg/day.
 28. The method of any one of claims 24-27,wherein the human milk composition is administered at about 90 to about100 mL/kg/day.
 29. The method of any one of claims 24-28, wherein thehuman milk composition is administered orally or enterally.
 30. Themethod of any one of claims 24-29, wherein the subject is about twoyears old or younger.
 31. The method of claim 17 or 30 wherein thesubject is a full term infant.
 32. The method of claim 17 or 30 whereinthe subject is a preterm infant.
 33. The method of claim 31 or 32wherein the infant is 7 days old or younger.